Search

Background: Corneal subepithelial infiltrates (SEIs) are characteristic clinical findings of adenoviral keratoconjunctivitis (AKC). In eyes with SEIs, both corneal opacity and irregular astigmatism may interfere with vision. However, irregular astigmatism is often overlooked in patients with AKC. Here, we report a case of decreased vision due to irregular corneal surfaces detected by Placido ring mires in eyes with corneal SEIs after AKC., Case Presentation: An 8-year-old girl with decreased vision was referred to our clinic. She had been diagnosed with AKC two years prior by a different physician. Thereafter, she experienced recurring episodes of decreased vision, epiphora, and photophobia in both eyes. The symptoms persisted despite resolution of the corneal opacity with steroid eye drops. Despite mild corneal opacity, both eyes exhibited distorted Placido ring patterns on corneal topography. The decreased vision in both eyes was due to the irregular corneal surface caused by SEIs, rather than corneal opacity. Topical 0.1% tacrolimus eye drops were effective in treating corneal opacity and irregular corneal surfaces., Conclusions: Our findings highlight that vision loss due to SEIs after AKC may stem from an irregular corneal surface regardless of corneal opacity severity, and the usefulness of a conventional and simple topography using Placido rings during treatment with 0.1% tacrolimus eye drops for SEIs in AKC., Competing Interests: Declarations. Ethics approval and consent to participate: This case report and the use of tacrolimus eye drops to treat SEIs after AKC were approved by the Institutional Review Board of Nagata Eye Clinic (#2018-004). Consent for publication: Written informed consent was obtained from the patient’s parents for the publication of this case. The patient’s anonymity was ensured. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: To assess the clinical characteristics, progression patterns, and treatment outcomes of microbiologically confirmed microsporidial keratoconjunctivitis (MKC)., Methods: This prospective cross-sectional study included patients with superficial punctate epithelial keratitis clinically suspected of MKC. Comprehensive slit-lamp examinations were conducted, and corneal scraping was performed for Gram-chromotrope staining and polymerase chain reaction (PCR) analysis. A standardized questionnaire gathered demographic data, clinical features, and risk behaviors. Treatment regimens and corneal findings, including medication and frequency, were documented at each visit., Results: PCR confirmed the diagnosis of MKC in 96 out of 117 eyes (82.1%), identifying Vittaforma corneae in 93.7% of cases, Microsporidium sp. in 4.2%, and Encephalitozoon hellem in 2.1%. All cases exhibited similar characteristics and pattern of progression, including elevated epithelial lesions in diffused distribution (34.1%), typical target lesions (31.3%), and subepithelial infiltrations (41.7%). Treatment with topical moxifloxacin, with or without oral albendazole, followed by topical steroids for subepithelial infiltrates, led to clinical improvement within approximately two weeks, with 52% of patients achieving complete recovery., Conclusions: This study identifies key clinical features and progression patterns in MKC. Topical fluoroquinolone monotherapy, or its combination with topical steroids or oral albendazole, results in favorable visual outcomes without corneal scarring. These insights may inform and enhance clinical management of MKC., Competing Interests: Declarations Conflict of interest The authors declare no competing interests. Ethical approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board Royal Thai Army Medical Department (ID: R053h/62)., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: The purpose of this study was to investigate the bacterial composition in the conjunctiva and to determine the relationship between fluoroquinolone resistance and mutations in the quinolone resistance-determining region (QRDR) in Corynebacterium macginleyi (C. macginleyi)., Methods: Bacteria isolated from conjunctival swabs of patients awaiting ophthalmic surgery or patients with presumed keratoconjunctivitis were included in this study. For C. macginleyi isolates from 49 samples, the minimum inhibitory concentrations (MICs) of second- to fourth-generation fluoroquinolones were determined by broth microdilution. Additionally, we determined the sequence of the QRDR in the gyrA gene of C. macginleyi-positive isolates by direct sequencing and investigated the relationship between the QRDR mutation and the MICs of fluoroquinolones for C. macginleyi., Results: Among 423 eyes of 296 preoperative patients who underwent conjunctival culture testing, 105 eyes of 89 patients were culture-positive, and among 148 eyes of 147 patients with keratoconjunctivitis, 55 eyes of 54 patients were culture-positive. C. macginleyi accounted for the largest proportion of cultured organisms (34.8%). C. macginleyi-positive isolates were found in 45 eyes of 37 preoperative patients and in 4 eyes of 4 patients with keratoconjunctivitis. Direct sequencing revealed that 91.8% of C. macginleyi-positive isolates had amino acid mutations in the QRDR and 95.5% of mutations were found at Ser-87 and Asp-91. Isolates harboring double mutations at Ser-87 and Asp-91 were resistant to second- to fourth-generation fluoroquinolones. One isolate with double mutations at Ser-87 and Ala-88 but no mutation in Asp-91 showed intermediate susceptibility to moxifloxacin, a fourth-generation fluoroquinolone., Conclusions: C. macginleyi isolated from conjunctiva harboring QRDR amino acid mutations were resistant to second- to fourth-generation fluoroquinolones.

Purpose: To evaluate the efficacy and safety of oral azithromycin treatment combined with topical antibiotic and anti-inflammatory agents in pediatric patients with chronic severe bilateral blepharokeratoconjunctivitis., Methods: Patients younger than 14 years with chronic and severe bilateral blepharokeratoconjunctivitis were reviewed retrospectively. Consecutive patients receiving oral azithromycin treatment were included. All patients received oral azithromycin (5 mg/kg/single dose daily) for at least 4 weeks combined with topical antibiotic and anti-inflammatory agents. Before and after the treatment, clinical symptoms were noted, and corneal and conjunctival fluorescein staining and corneal neovascularization were graded. Meibomian gland secretion and meibomian gland plugging were also assessed. All patients completed at least 3 months of follow-up after completion of the oral azithromycin treatment. Patients' clinical data at the time of diagnosis and last follow-up visit were statistically compared., Results: Twenty-nine children (58 eyes, mean age of 6.51 years) were included. The mean time of oral azithromycin use was 5.87 weeks (range: 4 to 10 weeks). Clinical symptoms and signs and visual acuity were significantly improved after treatment. The mean fluorescein staining and corneal neovascularization grades and meibomian gland secretion and meibomian gland plugging scores also improved after treatment ( P < .001). Eyelid distortion or fornix shortening was not observed. At the last follow-up visit, all patients were stable with treatment only with daily eyelid hygiene, topical cyclosporine, and artificial tears., Conclusions: Long-term, low-dose oral azithromycin combined with topical antibiotic and anti-inflammatory agents is an effective treatment option for pediatric patients with chronic severe bilateral blepharokeratoconjunctivitis. [ J Pediatr Ophthalmol Strabismus . 2024;61(5):358-364.] .

The aim of this article is to report clinical features and therapeutic approach of cicatrizing keratoconjunctivitis secondary to ocular lichen planus based on a case report. The patient is a 77-year-old female with a history of ocular discomfort and recurrent keratoconjunctivitis that did not improve with conservative treatment, as well as a history of oral and nasal aphthous ulcers. After a complete ophthalmologic, dermatologic and anatomopathological study, the diagnosis of ocular lichen planus was established and immunosuppressive treatment was initiated. Most cases of ocular lichen planus are presented as chronic cicatricial conjunctivitis. A correct differential diagnosis, as well as an early detection are essential for the control of this entity and its sequelae. Treatment, based on corticosteroids and immunosuppressants, both topical and systemic, is aimed at controlling inflammation and scarring., (Copyright © 2024 Sociedad Española de Oftalmología. Published by Elsevier España, S.L.U. All rights reserved.)

Streptococcus pyogenes (group A beta-hemolytic Streptococcus, GABHS) causes a range of human infections, including necrotizing fasciitis and toxic shock syndrome, because it produces exotoxins that damage host cells, facilitate immune evasion, and serve as T cell superantigens. GABHS conjunctivitis is rare. We report a case of membranous conjunctivitis in a 3-year-old child who was treated with a combination of targeted bactericidal antimicrobials, toxin-synthesis inhibition, and amniotic membrane transplantation., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Objective: To describe clinical features and management of toxic keratoconjunctivitis associated with punctal and (or) canaliculus stenosis (toxic soup syndrome)., Design: Retrospective observational case series., Methods: Electronic medical record database search for the keywords "toxic soup syndrome" and retrospective chart review were performed. Thirty-five eyes of 25 patients were seen at a tertiary cornea clinic between January 2017 and December 2021. Sex, age, distance-corrected visual acuity, topical medications, symptoms, clinical signs, and outcomes after medical and surgical interventions were analyzed. The main outcome measured was improvement in ocular surface signs and symptoms after interventions., Results: Overall, 35 eyes of 25 patients with a mean age of 66.8 ± 12.8 years, of which 72% were female, were included. The primary complaint was hyperemia and epiphora in all patients. Rosacea or meibomian gland disease were present in all patients, 7 (28%) had glaucoma, and 7 (28%) developed limbal stem cell deficiency. Twenty-two patients (88%) were using topical medications on presentation. All eyes had either punctal plugs, cauterized puncta, or punctal and (or) canaliculus stenosis. Management of all patients consisted of suspension of all preserved topical medications and institution of some type of anti-inflammatory therapy. Nineteen patients (76%) improved after improvement of lacrimal drainage. One patient with severe resistance in the canaliculus required ongoing preservative-free topical steroids., Conclusions: Chronic drug-induced or pooled inflammatory mediators causing toxic conjunctivitis may be aggravated by punctal and (or) canaliculus stenosis, leading to toxic soup syndrome. Clearance of punctal obstruction leads to improvement in most patients., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Gonorrhoea is on the rise: between 2021 and 2022, a 50% and a 33% increase in diagnoses was seen, respectively, in England and the Netherlands. A concurrent rise in gonococcal keratoconjunctivitis (GKC) is a serious concern due to the potentially devastating visual complications., Methods: This is a retrospective case series of adult GKC from two Western European tertiary ophthalmology centres between 2017 and July 2023. The clinical features, ocular complications and antimicrobial susceptibilities are reported within., Results: An increased incidence was recorded at both centres, with 11 confirmed cases in the first 7 months of 2023, compared with ≤3 per year in 2017-2022., Conclusion: The notable increase of GKC cases in our centres in 2023 may indicate a rise across Western Europe. Enhanced, sustained, national surveillance of GKC is essential to establish incidence and antimicrobial susceptibility, to inform treatment guidelines and guide appropriate public health response., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This meta-analysis aimed to review the safety and efficacy of topical cyclosporine A (CsA) and topical tacrolimus in allergic eye disease., Methods: A systematic search identified thirteen studies and a total of 445 patients for inclusion, making this the largest meta-analysis published on the subject. The current review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)., Results: Thirteen randomized control trials were included in the meta-analysis. Eleven studies used CsA as the treatment, and two used Tacrolimus. In total, 445 participants were included, of whom 76.6% were male. The mean age of participants across the included studies was 14 years. All studies reported clinical signs as evaluated by an examining clinician. Signs were usually assessed by anatomical region, with the most common regions being the conjunctiva and the cornea, and the most common signs assessed were hyperemia and papillae. Three studies accounted for more than 50% of the meta-analysis's weight. Effect size (d) ranged from - 2.37 to - 0.03, negative values favoring immunomodulators. Fixed Effect Meta-Analysis returned an SMD of - 0.81 (95% CI [- 0.98, - 0.65]). However, there was significant heterogeneity (I 2  = 61%, Q w  = 30.76) in the outcome measure (P = 0.0021); therefore, a random-effect meta-analysis was also completed in which the pooled SMD was - 0.98 (95% CI [- 1.26, - 0.69], τ 2  = 0.16)., Conclusions: This study affirms the current scientific community's stance that immunomodulators effectively treat clinical signs, including blepharitis, conjunctival hyperemia, edema, papillae, and corneal damage in severe ocular allergic disease., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Importance: Pediatric blepharokeratoconjunctivitis (PBKC) is a chronic, sight-threatening inflammatory ocular surface disease. Due to the lack of unified terminology and diagnostic criteria, nonspecific symptoms and signs, and the challenge of differentiation from similar ocular surface disorders, PBKC may be frequently unrecognized or diagnosed late., Objective: To establish a consensus on the nomenclature, definition, and diagnostic criteria of PBKC., Design, Setting, and Participants: This quality improvement study used expert panel and agreement applying the non-RAND modified Delphi method and open discussions to identify unified nomenclature, definition, and definitive diagnostic criteria for PBKC. The study was conducted between September 1, 2021, and August 14, 2022. Consensus activities were carried out through electronic surveys via email and online virtual meetings., Results: Of 16 expert international panelists (pediatric ophthalmologists or cornea and external diseases specialists) chosen by specific inclusion criteria, including their contribution to scientific leadership and research in PBKC, 14 (87.5%) participated in the consensus. The name proposed was "pediatric blepharokeratoconjunctivitis," and the agreed-on definition was "Pediatric blepharokeratoconjunctivitis is a frequently underdiagnosed, sight-threatening, chronic, and recurrent inflammatory eyelid margin disease associated with ocular surface involvement affecting children and adolescents. Its clinical spectrum includes chronic blepharitis, meibomitis, conjunctivitis, and corneal involvement ranging from superficial punctate keratitis to corneal infiltrates with vascularization and scarring." The diagnostic criteria included 1 or more suggestive symptoms accompanied by clinical signs from 3 anatomical regions: the eyelid margin, conjunctiva, and cornea. For PBKC suspect, the same criteria were included except for corneal involvement., Conclusions and Relevance: The agreements on the name, definition, and proposed diagnostic criteria of PBKC may help ophthalmologists avoid diagnostic confusion and recognize the disease early to establish adequate therapy and avoid sight-threatening complications. The diagnostic criteria rely on published evidence, analysis of simulated clinical cases, and the expert panel's clinical experience, requiring further validation with real patient data analysis.

Objective: The aim of this study was to describe the clinical features and management of uveitis associated with microsporidial keratoconjunctivitis (MKC)., Methods: The medical records of clinically diagnosed or microbiologically proven patients with MKC between July 2016 and August 2021 were reviewed. Patients with documented evidence of keratic precipitates (KPs) or anterior chamber cells were analyzed for their demography, clinical features, and treatment. Patients with microsporidial stromal keratitis and herpes simplex virus keratouveitis were excluded from the study., Results: Of the 2212 patients reviewed within the study period 171 of 172 eyes (7.7%) had documented evidence of KPs and/or anterior chamber cells. The patients' mean age was 43.8 ± 13.8 years, and there were more men (n = 120). The mean duration of appearance of KPs was 6.9 ± 5.5 days, and 28% (n = 48 of 171) appeared on the day of presentation. Superficial punctate keratitis was central and diffuse in 48 and 49 patients, respectively. The treatment was either lubricant alone (45.3%; 78 eyes) or combined with topical steroids (54.7%; 94 eyes). The mean duration of the resolution was longer in the "corticosteroid" than "no corticosteroid" group: KPs: 15.3 ± 6.5 days versus 12.3 ± 5.8 days ( P = 0.007) and superficial punctate keratitises: 15.4 ± 9.4 days versus 11.7 ± 6.2 days ( P = 0.01). The presenting visual acuity with a pinhole was 0.26 ± 0.26 (logMAR) and it improved to 0.03 ± 0.07 on resolution ( P < 0.0001, paired t test)., Conclusions: Uveitis after MKC is a self-limiting entity that often resolves without corticosteroid. One must exercise caution in using steroids in the presence of active corneal lesions., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate characteristics and outcomes of pediatric phlyctenulosis at a tertiary care center in the United States., Methods: A retrospective cohort study of phlyctenulosis diagnosis in patients younger than 18 years was conducted. Demographics, presenting features, treatment regimens, and outcomes were analyzed., Results: Seventy patients (95 eyes) with phlyctenulosis were identified. Fifty-four patients (77.1%) were Hispanic, which was greater than the center's proportion of pediatric patients identifying as Hispanic (53.8%, P < 0.0001). Common comorbidities included adjacent external/lid disease (82.9%), allergic/atopic disease (18.6%), and viral infections (8.6%). Nine patients had tuberculosis testing which was negative in all cases. Five patients had vitamin A testing which revealed deficiency in 1 patient. Treatment regimens were diverse and included varying combinations of topical and systemic medications. Complications included corneal scarring (27.4%), corneal neovascularization (40.0%), amblyopia (16.8%), corneal perforation (3.2%), and severe limbal stem-cell deficiency (1.1%). 26.3% of affected eyes had final visual acuity worse than 20/40. Differences in rates of corneal complications between Hispanic and non-Hispanic patients were not statistically significant, although severe corneal complications including perforation occurred only in the Hispanic group., Conclusions: This study presents a modern cohort of phlyctenulosis at a tertiary center in the United States and includes a larger proportion of Hispanic patients than expected. Phlyctenulosis carries high corneal morbidity and may frequently result in reduced visual acuity. Similar rates of corneal complications were seen in Hispanic versus non-Hispanic patients, but severe corneal complications were seen only in the Hispanic group., Competing Interests: Conflicts of interest statement: S. Jain—Ocugen, Inc: Consultant, Neutrolis, Inc: Consultant, Advaite, Inc: Corporate Board Member, Selagine, Inc: Stock Shareholder. E. Y. Tu—Eversight: Scientific/Medical Advisory Board Member, GSK: Consultant, Oyster Point Pharma: Scientific/Medical Advisory Board Member, Daiichi Sankyo: Consultant, Gore: Consultant. The remaining authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to describe a case of corneal involvement as an early manifestation of ocular disease in the 2022 human mpox (monkeypox) virus outbreak., Methods: This is a single case report with longitudinal care., Results: A 47-year-old immunocompetent man presented with viral conjunctivitis before development of skin lesions or systemic symptoms. Subsequently, he developed membranous keratoconjunctivitis and a corneal epithelial defect. Orthopoxvirus-positive polymerase chain reaction test from his ocular surface was positive. The epithelial defect did not heal with conservative treatment but was successfully treated with amniotic membrane transplantation over 8 days. Reduced corneal sensation was noted after epithelial healing, and polymerase chain reaction from the ocular surface remained positive at 17 days from symptom onset, with slowly recovering conjunctivitis at 21 days. Continued membrane formation required repeated removal but significantly improved with topical corticosteroid treatment after epithelial healing by 29 days of symptom onset. Corneal sensation normalized by 87 days from symptom onset at which time symblepharon were noted but PCR testing from the ocular surface was negative., Conclusions: Early corneal involvement of human monkeypox virus is possible. Transient corneal hypoesthesia may be due to acute inflammation. Chronic inflammatory changes can result in symblepharon. These findings have potential implications in patient care and corneal donation., Competing Interests: Conflict of interest statement: The authors have no financial disclosures or conflicts of interest. Written consent was obtained from the patient., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Epidemic keratoconjunctivitis (EKC) is a highly contagious infectious ocular disease that has been widespread worldwide. Ophthalmic preparations of glucocorticoids (OPGs) are the supportive therapies for EKC; however, they are still controversial., Methods: We performed a systematic review and meta-analysis to evaluate the efficacy and safety of OPGs in patients with EKC. Electronic searches were conducted in PubMed, Embase, the Cochrane Library, ClinicalTrials.gov, China National Knowledge Internet (CNKI), and Wanfang Database from inception to 25 Aug 2022. We included and analyzed randomized controlled trials (RCTs) and cohort studies that compared OPGs to other positive drugs or placebo in patients with EKC., Results: Six studies (five RCTs and one retrospective cohort) involving 286 patients were included in the analysis. Compared with artificial tears, OPGs could relieve ocular symptoms faster in the acute phase of epidemic keratoconjunctivitis (AEKC). There was no significant difference in the incidence of corneal subepithelial infiltrates (SEIs) in AEKC when OPGs were used for 7 days, but there was a substantial difference for 21 and 28 days. In the chronic phase of epidemic keratoconjunctivitis (CEKC), there was no significant difference in the rate of complete elimination of SEIs at 6 months of OPGs treatment compared with immunosuppressants [RR = 1.07,95%CI (0.71,1.61), p = 0.75], as well as in the recurrence rate of SEIs after 6 months [RR = 2.05,95%CI (0.82,5.12), P = 0.13]. OPGs significantly increased intraocular pressure (IOP) at 6 months compared with immunosuppressants [MD = - 1.13,95%CI (- 1.97, - 0.30), P = 0.007]. There was no significant difference in cessation of therapy due to drug intolerance between OPGs and immunosuppressants [RR = 0.69,95%CI (0.16,2.94), p = 0.62]., Conclusions: OPGs might relieve ocular symptoms and reduce the incidence of SEIs in AEKC, whereas not recommended the therapy in CEKC. More high-quality clinical evidence is required to confirm our findings., (© 2022. The Author(s), under exclusive licence to The Drug Information Association, Inc.)

Purpose: The purpose of this study was to determine the clinical characteristics, disease course, therapeutic outcomes, and prognostic factors for pediatric patients with blepharokeratoconjunctivitis (BKC)., Methods: A retrospective medical chart review was performed for patients aged 15 years or younger who had been diagnosed with BKC between 2004 and 2020 at 2 tertiary hospitals in Korea. The following data were collected: demographics, medical history, ocular findings, geometric profiling of corneal lesion, medical management, and outcomes., Results: A total of 137 patients (90 female and 47 male) were included. The patients' mean age was 8.3 ± 3.8 years at disease onset. Both eyes were involved in 57.7% of cases. The most common corneal lesion was corneal neovascularization (77.4%), followed by clinically visible corneal infiltration (51.8%) and stromal scarring (43.1%). Most of the corneal lesions involved a single quadrant, most commonly the inferior quadrant. After treatment, disease remission was achieved in 95% of patients, and visual acuities improved from 0.2 ± 0.3 logarithm of minimal angle of resolution at disease presentation to 0.1 ± 0.3 logarithm of minimal angle of resolution at final follow-up ( P = 0.001). Recurrence occurred in 52.6% of patients. Cylinder power was significantly higher in patients with recurrence than in those without. The number of cases of recurrence was positively associated with final cylinder power., Conclusions: Although the treatment induced disease remission in 95% of children with BKC, recurrence occurred in 52.6% of those cases. Because recurrence resulted in significant astigmatism, careful observation for recurrence and prompt management are warranted for preservation of vision in pediatric patients with BKC., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the in vitro efficacy of cidofovir, ganciclovir, povidone-iodine, chlorhexidine, and cyclosporine A on adenovirus genotype 8., Methods: Conjunctival samples were collected from patients with adenoviral conjunctivitis and cultured in A549 cells. Adenovirus diagnosis was confirmed by RT-PCR. For each drug, the 50% cytotoxic concentration (CC 50 ) was determined. Subsequently, the antiviral activity was tested at concentrations below CC 50, and the 50% inhibitor concentration (IC 50 ) of drugs was determined RESULTS: While the IC 50 of cidofovir against adenovirus genotype 8 was 3.07 ± 0.8 µM, ganciclovir, povidone-iodine, chlorhexidine, and cyclosporine A were not found to be effective against adenovirus genotype 8 at concentrations below the CC 50 value., Conclusions: Cidofovir was found effective and the IC 50 value was within the ranges in the literature. Ganciclovir and cyclosporine A were found to be ineffective at doses below the cytotoxic dose, povidone-iodine and chlorhexidine was found to be highly cytotoxic., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To report a case of a male patient with a severe corneal and conjunctival immunopathy likely caused by an X-linked agammaglobulinemia., Methods: A clinical case report with observation results from 2001-2021., Results: A severe corneal immunopathy of both eyes is reported in a retrospective long-term observation of nearly twenty years in a 32-year-old male patient with X-linked agammaglobulinemia (XLA). A chronic progressive corneal scarring with a loss of visual acuity and typical symptoms of a phlyctenular keratoconjunctivitis were observed., Conclusion: Whereas steroid eye drops like dexamethasone could control the symptoms and the corneal scarring progression as short time therapy options, ciclosporin A eye drops showed problems in therapy adherence in long-time use. Antibiotic eye drops supported the anti-inflammatory therapy effects, but no typical pathogen was detected. Antineovascular subconjunctival application did not show any relevant effect in one-time use. Artificial tears were needed as basic therapy.

Epidemic keratoconjunctivitis (EKC) is a hazardous and highly contagious disease, with the potential to cause epidemic outbreaks in hospitals and other community settings. There are currently no approved drugs for human adenovirus (HAdV), the causative agent of EKC. To establish a novel drug screening system for ocular HAdV infections, we employed CRL11516, a non-cancerous but immortalized human corneal epithelial cell line. Brincidoforvir and 3'-deoxy-3'-fluorothymidine inhibit replication of HAdV species C type 1 (C1), C2, E4, and C6 to the same extent. This alternative assay system may allow for the evaluation of anti-HAdV activity and cell cytotoxicity of compounds within 2 days and without the need of the rabbit eye infection model., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To explore the effects of cyclosporine A (CsA) in the management of atopic keratoconjunctivitis (AKC)., Methods: Open single-group interventional consecutive cohort study (case series) at a single eye care facility in the UK. We reviewed the electronic patient records of 99 children and young people (CYP) aged 3.4-18 years with AKC treated with topical CsA 1 mg/ml. Main outcome measures were number of prescriptions and hospital clinic visits over 12 months before and after the start of CsA and the proportion of CYP affected by adverse effects., Results: The median number of inflammatory episodes requiring treatment with topical corticosteroids (tCS) fell from 3 (interquartile range IQR 1-4) during the 12 months prior to CsA to 1 (IQR 0-3) during the 12 months after, excluding tCS prescriptions with the first CsA prescription (Wilcoxon signed ranks test, 2 tailed, p < 0.01). In the 12-month period following initiation of CsA 1 mg/ml with concomitant prescription of tCS (n = 66), daily dosage of steroids was reduced in 62 CYP (93.9%), and they were discontinued in 43 (65.2%). The median number of hospital visits fell from 4 (IQR 3-6) to 3 (IQR 2-5; Wilcoxon p < 0.01). Adverse events leading to discontinuation of CsA were stinging (instillation site pain; 9/99, 9%) and a transient skin rash (1/99, 1%)., Conclusions: Off-label use of commercial preparations of CsA 1 mg/ml significantly reduces the need for concomitant topical corticosteroids and hospital clinic visits in CYP with AKC. Stinging and skin rash can lead to discontinuation., (© 2022 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Pinkeye (a generic term to describe infectious bovine keratoconjunctivitis) is a significant disease of cattle worldwide, impacting productivity and animal welfare. One commercial pinkeye vaccine, a systematically administered Moraxella bovis bacterin, has been available in Australia since 2007. This is the first field trial of the effectiveness of this vaccine for the prevention of naturally occurring disease in Australia. Extensively run beef herds in southwest Queensland that regularly experienced pinkeye were enrolled in the trial and animals were randomly allocated to vaccinated and control groups in different proportions in each herd. The subsequent incidence of clinical pinkeye between the two groups was compared for animals less than one-year-old. Data were analysed from 649 cattle from five herds over two pinkeye seasons: three herds of 390 calves from 1st November 2019 to 20th January 2020 and two herds of 259 calves from 23rd September 2020 to 21st April 2021. Pinkeye was common with 24% of all calves (156/649) contracting the disease during the trial. Univariable and multivariable binary logistic mixed-effect models were fitted to account for clustered data and potential residual confounding due to sex, weight, breed, coat colour, and periocular pigmentation. The incidence of pinkeye was not significantly different between vaccinated and control groups, both alone (p = 0.67) and after adjusting for sex and weight differences (p = 0.69). The vaccine was not protective against naturally occurring pinkeye under the field conditions., Competing Interests: Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The incidence of chronic keratoconjunctivitis, which potentially causes long-term loss of visual acuity due to corneal opacity, is considerably less common in children than in adults. It is therefore in danger of being overlooked. In children the appropriate treatment is therefore often introduced too late, or to an insufficient extent. In this article we would like to raise awareness about the diagnosis of chronic keratoconjunctivitis in children, and to present an effective treatment plan for severe stages of the disease. There are two forms of chronic keratoconjunctivitis that occur most frequently in children: hyperergic blepharokeratoconjunctivitis (hBKC) and vernal keratoconjunctivitis (VKC). With hBKC, the patient often has a history of recurring hordeolum and also presents with blepharitis; it is characterized by the marked presence of corneal neovascularization in the lower circumference of the cornea. VKC is typically characterized by changes under the upper eyelid, with marked changes to the superior limbus. If there is a risk of complications involving the cornea, or in the presence of such complications, a consistent long-term topical immunosuppressive and anti-inflammatory treatment is required. Both of these properties are combined in the active ingredient cyclosporine A. Other advantages of topical CSA treatment are its steroid-sparing effect and the long-term reduction of exacerbations. Parents need to be informed about the chronic nature of these two diseases and their tendency to recur; because of these characteristics, treatment, in most cases, should be envisaged for at least one year in order to effectively disrupt the complex immunologic processes. This safeguards the child's visual development and prevents amblyopia caused by scarring and astigmatism. We hope that the data presented will lower the barriers related to prescribing CSA for topical eye application in children., Competing Interests: Prof. Eter: Fa. Novartis: Research Funding, Speakerʼs Honoraria, Study grant to department, Advisory Board. Fa. Bayer: Research Funding, Speakerʼs Honoraria, Consultant fees, Advisory Board. Fa. Allergan: Research Funding, Speakerʼs Honoraria, Advisory Board. Fa. Roche: Advisory Board. Advisor: Apellis Pharmaceuticals, Alcon, Bayer, Novartis, Roche. Lecture fees: Apellis Pharmaceuticals, Bayer, Novartis, Roche. Research grant: Bayer, Novartis. Prof. Biermann: Santhera and Streamedup: Speakerʼs Honoraria. Bielschowsky-Gesellschaft: Research Funding./Prof. Eter: Forschungsförderung und Vortragshonorare von Novartis, Bayer, Allergan. Beratertätigkeit für Apellis Pharmaceuticals, Bayer, Novartis, Roche. Prof. Biermann: Vortragshonorar Santhera und Streamedup. Forschungsförderung der Bielschowsky-Gesellschaft., (Thieme. All rights reserved.)

Blepharokeratoconjunctivitis, (BKC) is a common ocular surface chronic inflammatory disease in children. It can cause eye irritation or even visual impairment. At present, the etiology of BKC in children is not clear and relevant studies are in the initial stage, consequently, there has not been an authoritative applicable expert consensus in China. Compared with adults, the clinical manifestations of pediatric patients are often atypical, coupled with the lack of understanding, so inadequate diagnosis and treatment are still exist in pediatric BKC. This article reviews the etiology, diagnosis and treatment status, clinical characteristics, standardized diagnosis and treatment of pediatric BKC, in order to arouse the attention of ophthalmologists.

Purpose: The aim of this study was to report corneal angiography features in subclinical limbitis in a patient with atopic keratoconjunctivitis., Methods: This is a case report., Results: A 22-year-old woman with a medical history of atopic keratoconjunctivitis was referred for bilateral corneal neovascularization with scarring. On examination, no signs of active disease were noticed at the slit lamp. Ocular surface angiography detected active corneal limbitis, showing as limbal leakage at fluorescein angiography in the early phase and leakage after indocyanine green angiography in the late phase. The patient was treated with topical corticosteroid. At follow-up, the fluorescein angiography and indocyanine green angiography no longer showed limbal leakage, whereas the slit lamp examination was unchanged., Conclusions: Active allergic corneal limbitis may present as subclinical inflammation, with no signs of activity at the slit lamp examination. Therefore, its diagnosis can be challenging without the use of corneal angiography., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To summarize key findings from a Cochrane systematic review of the effectiveness and safety of topical pharmacologic interventions compared with active control or placebo for epidemic keratoconjunctivitis (EKC)., Design: Systematic review., Methods: We included randomized controlled trials that compared antiseptic agents, virustatic agents, or immune-modulating topical therapies with placebo or an active control. We adhered to Cochrane methods for trial selection, data extraction, risk of bias evaluation, and data synthesis., Results: Ten randomized controlled trials with 892 participants with acute or chronic EKC were included. Eight trials compared interventions with artificial tears or saline (n = 4) or with steroids (n = 4); two 3-arm trials contributed data to both comparisons. Estimates suggested that compared with tears, after povidone-iodine (PVP-I) alone (2 studies, 409 participants) more participants with acute EKC had resolution of symptoms (risk ratio [RR] 1.15 [95% confidence interval {CI} 1.07-1.24]) and signs (RR 3.19 [95% CI 2.29-4.45]) within 10 days. In 2 trials comparing treatments with steroid alone or steroid with levofloxacin, fewer eyes treated with PVP-I or polyvinyl alcohol iodine (PVA-I) plus steroid developed subepithelial infiltrates within 21 days (RR 0.08 [95% CI 0.01-0.55]; 69 eyes). No treatment was shown to improve resolution of infiltrates., Conclusions: Low- to very low-level certainty of evidence suggested that PVP-I or PVA-I with steroid may confer some benefit in acute EKC, but imprecision from small sample sizes, the potential risk of bias from inadequate reporting or trial design, and variability in participant selection, outcome measurement, and reporting limit the amount and quality of evidence., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To report a case of severe bilateral phlyctenular keratoconjunctivitis (PKC) associated to hidradenitis suppurativa (HS)., Case Report: A 26-year-old male with reactivation of HS in the last few months presented with concurrent pain and vision loss secondary to bilateral PKC resistant to topical treatment. There were no other infectious or autoimmune disorders. Systemic immunosuppression was needed, with simultaneous improvement of the ophthalmological and dermatological findings., Conclusions: Different inflammatory eye diseases have been reported in the context of HS. Acute inflammation in HS reactivation would trigger an autoimmune response, acting as a common causal mechanism in this association. We have reported a new case of inflammatory eye disease - HS in the form of PKC, not previously described in the literature, and consistent with immune dysregulation where the systemic Staphylococcus aureus burden due to HS may act as an additional causal factor.

Background: Viruses cause about 80% of all cases of acute conjunctivitis. Human adenoviruses are believed to account for 65% to 90% of cases of viral conjunctivitis, or 20% to 75% of all causes of infectious keratoconjunctivitis worldwide. Epidemic keratoconjunctivitis (EKC) is a highly contagious subset of adenoviral conjunctivitis that has been associated with large outbreaks at military installations and at medical facilities. It is accompanied by severe conjunctival inflammation, watery discharge, and light sensitivity, and can lead to chronic complications such as corneal and conjunctival scarring with discomfort and poor quality of vision. Due to a lack of consensus on the efficacy of any pharmacotherapy to alter the clinical course of EKC, no standard of care exists, therefore many clinicians offer only supportive care., Objectives: To assess the efficacy and safety of topical pharmacological therapies versus placebo, an active control, or no treatment for adults with EKC., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 4); Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Sciences database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), with no restrictions on language or year of publication. The date of the last search was 27 April 2021., Selection Criteria: We included randomized controlled trials in which antiseptic agents, virustatic agents, or topical immune-modulating therapy was compared with placebo, an active control, or no treatment., Data Collection and Analysis: We used standard Cochrane methodology., Main Results: We identified 10 studies conducted in Asia, Europe, the Middle East, and North Africa with a total of 892 participants who were treated for 7 days to 6 months and followed for 7 days up to 1.5 years. Study characteristics and risk of bias In most studies participants were predominantly men (range: 44% to 90%), with an age range from 9 to 82 years. Three studies reported information on trial registration, but we found no published study protocol. The majority of trials had small sample sizes, ranging from 18 to 90 participants enrolled per study; the only exception was a trial that enrolled 350 participants. We judged most studies to be at high or unclear risk of bias across risk of bias domains. Findings We included 10 studies of 892 EKC participants and estimated combined intervention effects in analyses stratified by steroid-containing control treatment or artificial tears. Six trials contributed to the comparisons of topical interventions (povidone-iodine [PVP-I], trifluridine, ganciclovir, dexamethasone plus neomycin) with artificial tears (or saline). Very low certainty evidence from two trials comparing trifluridine or ganciclovir with artificial tears showed inconsistent effects on shortening the mean duration of cardinal symptoms or signs of EKC. Low certainty evidence based on two studies (409 participants) indicated that participants treated with PVP-I alone more often experienced resolution of symptoms (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.07 to 1.24) and signs (RR 3.19, 95% CI 2.29 to 4.45) during the first week of treatment compared with those treated with artificial tears. Very low certainty evidence from two studies (77 participants) suggested that PVP-I or ganciclovir prevented the development of subepithelial infiltrates (SEI) when compared with artificial tears within 30 days of treatment (RR 0.24, 95% CI 0.10 to 0.56). Four studies compared topical interventions (tacrolimus, cyclosporin A [CsA], trifluridine, PVP-I + dexamethasone) with topical steroids, and one trial compared fluorometholone (FML) plus polyvinyl alcohol iodine (PVA-I) with FML plus levofloxacin. Evidence from one trial showed that more eyes receiving PVP-I 1.0% plus dexamethasone 0.1% had symptoms resolved by day seven compared with those receiving dexamethasone alone (RR 9.00, 95% CI 1.23 to 66.05; 52 eyes). In two trials, fewer eyes treated with PVP-I or PVA-I plus steroid developed SEI within 15 days of treatment compared with steroid alone or steroid plus levofloxacin (RR 0.08, 95% CI 0.01 to 0.55; 69 eyes). One study found that CsA was no more effective than steroid for resolving SEI within four weeks of treatment (RR 0.84, 95% CI 0.67 to 1.06; N = 88). The evidence from trials comparing topical interventions with steroids was overall of very low level certainty. Adverse effects Antiviral or antimicrobial agents plus steroid did not differ from artificial tears in terms of ocular discomfort upon instillation (RR 9.23, 95% CI 0.61 to 140.67; N = 19). CsA and tacrolimus eye drops were associated with more cases of severe ocular discomfort, and sometimes intolerance, when compared with steroids (RR 4.64, 95% CI 1.15 to 18.71; 2 studies; N = 141). Compared with steroids, tacrolimus did not increase the risk of elevated intraocular pressure (RR 0.07, 95% CI 0 to 1.13; 1 study; N = 80), while trifluridine conferred no additional risk compared to tear substitute (RR 5.50, 95% CI 0.31 to 96.49; 1 study; N = 97). Overall, bacterial superinfection was rare (one in 23 CsA users) and not associated with use of the intervention steroid (RR 3.63, 95% CI 0.15 to 84.98; N = 51). The evidence for all estimates was of low or very low certainty., Authors' Conclusions: The evidence for the seven specified outcomes was of low or very low certainty due to imprecision and high risk of bias. The evidence that antiviral agents shorten the duration of symptoms or signs when compared with artificial tears was inconclusive. Low certainty evidence suggests that PVP-I alone resolves signs and symptoms by seven days relative to artificial tears. PVP-I or PVA-I, alone or with steroid, is associated with lower risks of SEI development than artificial tears or steroid (very low certainty evidence). The currently available evidence is insufficient to determine whether any of the evaluated interventions confers an advantage over steroids or artificial tears with respect to virus eradication or its spread to initially uninvolved fellow eyes. Future updates of this review should provide evidence of high-level certainty from trials with larger sample sizes, enrollment of participants with similar durations of signs and symptoms, and validated methods to assess short- and long-term outcomes., (Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Purpose: To evaluate the clinical improvement and safety of prolonged treatment of vernal (VKC) and atopic keratoconjunctivitis (AKC) using topical tacrolimus., Methods: We included 36 eyes of 36 patients who had VKC and AKC and were treated with topical tacrolimus ophthalmic suspension (0.1%) for 24 months. The demographic data of the enrolled patients were collected from their medical files. Clinical scores, remission rates, number of relapses, concomitant use of steroids, and refractory indices were assessed. Clinical outcomes were determined using papillae-limbus-cornea (PLC) scores and 5-5-5 exacerbation grading scale scores. Clinical characteristics associated with the need for concomitant steroid eye drops administration were determined using logistic regression analysis. All patients were classified into 3 subgroups using cluster analysis., Results: PLC scores recorded in the sixth month were significantly improved compared with those recorded at baseline. PLC scores recorded in the 18th, 21st, and 24th months were significantly improved compared with those recorded in the sixth month. The remission rates increased diachronically and significantly, reaching 92% in the 24th month. Logistic regression analysis showed that, for every 10-year increase in patient age, the risk for requiring concomitant administration of steroid eye drops was reduced by half (odds ratio, 0.53; 95% confidence interval, 0.29-0.96). Using cluster analysis, the patients were divided into 3 clusters: adolescent type, pediatric type, and adult type., Conclusions: Two years of treatment with topical tacrolimus ophthalmic suspension is an effective method for inducing and maintaining the stable stages of VKC and AKC., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To improve the treatment of adenoviral lesions of the eye based on express diagnostics by the fluorescent antibody technique (FAT) and the use of modern drugs., Material and Methods: The study included 184 patients (333 eyes) with various manifestations of adenoviral lesions of the ocular surface, who were divided into two groups: group 1 (149 patients, 196 eyes) - acute form, and group 2 (76 patients, 137 eyes) - long lasting form. Effectiveness of the proposed treatment was evaluated against separate group 3 (controls) consisting of 28 people (46 eyes) with completed acute adenovirus infection, who had previously received antibiotic and corticosteroid therapy in other clinics. Conjunctival scrapings of study patients were examined with FAT in our proposed modification. Study patients received local therapy with modern drugs (Okomistin, Aktipol)., Results: FAT detected the adenovirus antigen in 169 cases in group 1 (86%) and in 99 cases in group 2 (72%). Treatment duration amounted to 12±6 days in group 1, 18±8 days in group 2, and 29±7 days in controls. In both study groups, the duration of treatment was significantly reduced in comparison with the controls ( p <0.01). Stable clinical effect and complete restoration of visual acuity have been achieved in most cases. There were no allergic and side effects from the therapy., Conclusion: Fluorescent antibody technique is a fast and effective way to diagnose adenovirus infection in ophthalmology. In terms of therapy, the use of an antiseptic, an antiviral drug and diluted corticosteroids is the most rational approach.

Purpose: Epidemic keratoconjunctivitis (EKC) is one of the most severe ocular viral infections. The aim of this interruptive time series study was to quantitatively evaluate the effectiveness of a hygienic EKC outbreak management concept developed in our ophthalmological department., Methods: All patients with suspected EKC in the period from August to November 2018 were included in the study. Data were retrospectively collected from the patient's medical documents and records. The disease was diagnosed clinically and confirmed by virus detection through polymerase chain reaction (PCR) from conjunctival swabs. With the beginning of the epidemic, an outbreak management plan was implemented to reduce the nosocomial spread., Results: The outbreak lasted 77 days (20th August 2018 to 4th November 2018) and affected a total of 120 patients. This corresponds to a mean of 1.5 patients per outbreak day. The median age was 58 [1-92] years. Of all patients, 61 (50.8%) were female. Conjunctival swabs were collected in 100/120 (83.3%) cases, the adenovirus being detected in all positive smears (63/63, 100%). The implementation of our outbreak management plan reduced significantly the number of EKC cases per outbreak day and resulted in a reduction of the basic reproduction number by a factor of 2.2., Conclusion: The detection of EKC together with the immediate implementation of hygienic outbreak measures can significantly reduce the spread of infection. The implementation of a strict outbreak management concept can significantly reduce the number of EKC cases, thus avoiding possible complications and therefore unnecessary health-related costs., (© 2021. The Author(s).)

Objectives: To analyze the effect of the employment of polyvinylpyrrolidone-iodine (PVP-I) 0.6% eye drop on the clinical course of patients affected by Adenoviral Keratoconjunctivitis (AKC)., Methods: Consecutive patients with clinical signs of AKC and positive results of AdenoPlus test were enrolled from four Italian Centres. Patients were randomized to receive: PVP-I 0.6% eye drops four times/daily for 20 days (Group A) or hyaluronate-based tear substitutes four times/daily for 20 days (Group B). Best-corrected visual acuity (BCVA), optical coherence tomography (OCT) Optovue iVue pachymetry map; corneal haze; conjunctival injection and chemosis; subepithelial corneal infiltrates (SEIs); corneal and conjunctival staining and corneal densitometry were recorded at diagnosis and at every follow-up visit. The primary outcome was the resolution time of AKC., Results: Overall, 59 AKC patients (34 for Group A and 25 for Group B) completed the study. Patients of Group A showed a significantly shorter resolution time and lower incidence of SEIs compared to patients of Group B. In particular, SEIs were present at the last visit in 3/34 (8.82%) patients of the Group A vs 11/25 (44%) of the Group B (p = 0.005). Patients of Group A showed a significantly lower incidence of corneal haze compared to patients of Group B (0/34 vs 3/25; p = 0.038). No side effects were reported for both groups., Conclusions: Although further clinical evaluations are needed, according to our data the use of PVP-I 0.6% eye drop in the setting of AKC reduces the risk of SEIs as well as the resolution time of the disease., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited part of Springer Nature.)

Purposes: A case of gonococcal keratoconjunctivitis rapidly diagnosed by a vaginal swab PCR Xpert® CT/NG assay., Methods: Case report., Results: A 26-year-old woman presented to our emergency department with severe perilimbal stromal melting in both eyes and profuse purulent discharge for one day. Upon emergent ocular consultation, gonococcal keratoconjunctivitis was suspected. A vaginal swab was sent for rapid PCR Xpert® CT/NG assay which reported positive Neisseria gonorrhoeae (NG) and Chlamydia Trachoma (CT) DNA detection within 90 min. Due to the rapid diagnosis, adequate medical intervention with ceftriaxone injection was administered. Gonococcal keratitis with stromal melting was stabilized within 5 days of presentation. The patient was discharged with complete epithelial healing by the 8th day. However, 10 weeks after discharge, inadvertent rubbing of the left eye resulted in corneal perforation with iris prolapse. Lamellar keratoplasty with corneal patch graft was performed with amniotic membrane grafting. Xpert® CT/NG assay was performed again with conjunctival swab for recurring mild eye discharge. Both NG and CT were negative. The patient thus stabilized with no further complications., Conclusions: Rapid stromal melting can occur with un-diagnosed or delayed diagnosis of gonorrhea with ocular involvement. Speedy and accurate diagnosis by the highly sensitive and specific Xpert® CT/NG assay can provide early definite diagnosis for prompt treatment in prevention of gonococcal infection induced corneal perforations.

Purpose : To examine the effects of treatments performed on children with adenoviral conjunctivitis. Methods : 50 children with Adenoviral keratoconjunctivitis (AK) were evaluated. Patients were divided into four groups according to the medical treatment agents that were used previously. AK symptoms were clinically scored and analyzed. The diagnosis of all children was confirmed by an in-office lateral flow immunoassay. Results : Fifty patients with AK were included in the study. 24 (48%) were female and 26 (52%) were male. The mean age was 12.88 ± 2.66 (8-17). In PVP-I groups clinical findings shows faster improvement than other groups ( p < .05). Conclusions : Conjunctival irrigation with 2.5% PVP-I is very effective for the treatment of adenoviral conjunctivitis in childhood. Ganciclovir ophthalmic gel 0.15% increases the effect of 2.5% PVP-I on AK, but this was not statistically significant.

Background and objective : To describe the clinical course and propose a morphological classification scheme of microsporidial keratoconjunctivitis. Methods : This is a prospective study at L V Prasad Eye Institute, Odisha, between August-January (2017-19). Patients of any age or sex, microbiologically proven as microsporidial keratoconjunctivitis were included. Demographic parameters, history, clinical course, and visual outcome were analysed. All received artificial tear substitutes till resolution and topical immunosuppressants used in cases of persisting sub-epithelial infiltrates (SEI) beyond 2 weeks. Results : Fifty-three eyes of 47 cases were included with males, 72.3%. Corneal lesions were classified into 3 morphological types- coarse, ring, and flat-topped (Type1, 2 & 3). Depending upon the location, Type 1 was further sub-divided into peripheral, paracentral, central, and diffuse (Type 1a, b, c & d). The mean age was highest in Type 3( p = .026). Risk factors and prior steroid use were most common in Type 1d. The mean duration of symptom before presentation was longest in Type 3(11.6 ± 3.65) days. Severe conjunctival congestion at presentation in more than half of the eyes were seen in Type 1a, 1b and 1d, with moderate congestion at Day14 persisting in 66.7% and 40% of eyes belonging to Type 1c and 1d, respectively. Keratic precipitates were most common in Type 2. The mean duration of resolution was longest in Type 1d (38 ± 15.87) days and shortest in type 1b (7.88 ± 2.47) days ( p = .022). Persistent SEIs beyond Day 90 were seen in total of 6 (11.3%) (Type 1c & 1d- 3 each) eyes and recurrent SEIs in 7(13.2%) (Type 1c-2 & 1d- 5) eyes. The mean duration of topical steroids use was longest in Type 1d (49.3 ± 22.3) days, followed by Type 1c (28 ± 0) days. Conclusion : Microsporidial keratoconjunctivitis can have a variable clinical presentation, the course of each being different depending on the host and ocular surface factors. Though considered as a self-limiting disease, central and diffuse coarse variety (Type1c&1d) required long-term topical immunosuppressants and follow-up.

Abstract: The coronavirus disease 2019 global pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several ophthalmic manifestations have been reported to be associated with SARS-CoV-2 infection, including conjunctivitis, acute sixth nerve palsy, and multiple cranial neuropathies. We present a unique case of unilateral phlyctenular keratoconjunctivitis in a 5-year-old boy in the setting of SARS-CoV-2 infection., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose : To evaluate adherence to topical medication in patients with inflammatory eye disease. Methods : Questionnaire survey of patients attending inflammatory eye disease clinics. Treatment regimen was validated against hospital-generated clinic letters. Results : There were 86 patients (52 uveitis and 34 ocular surface disease) with 30% (26/86) failing to identify one or more of the medications they were using, and 28% (24/86) unable to offer the correct indication for their treatment. A total of 64% (55/86) failed to use their medication as advised (27% on a daily basis); the commonest reason being forgetfulness. In patients using multiple eye drops, 26% left insufficient time intervals between successive eye drops, and 58% (50/86) reported not being given any instruction on drop instillation. Conclusions : We highlight poor adherence to topical medication in patients with inflammatory eye disease. We recommend a dedicated practitioner providing a proactive approach to patient education to improve adherence.

Purpose: : To characterize the sequelae of microsporidia keratoconjunctivitis (MKC) and outline its management., Methods: Retrospective analysis of microbiologically proven MKC returned with persistent disease between January 2015 and December 2019 was done. Demographics, clinical features, management, and outcome were analyzed., Results: Sixteen patients (21 eyes) of 332 treated for MKC returned with the persisting disease. The mean age of 11 males (68.7%), and 5 females was 35.1 ± 12.2 years. Three-quarter of them did not have a known predisposing risk factor and one-quarter of them were referred for chronic conjunctivitis. Past medications included topical antivirals (n = 8) and topical corticosteroid (n = 6). Three predominant presentations were persistent (>3 weeks) superficial punctate keratitis (SPKs, n = 7), sub-epithelial infiltrates (SEIs, n = 13), and uveitis (n = 2). The lesions recurred in eight eyes (SPK and SEI 4 each) after a disease-free interval of 60.4 ± 40.6 days; there were 13 episodes of recurrence. Topical low potent corticosteroids (loteprednol/fluorometholone), and tacrolimus ointment 0.03% were used in 17 (80.9%) and 8 (38%) eyes, respectively, for a mean duration of 44.8 ± 31.6 and 226.8 ± 180.5 days, respectively. At follow-up, 172.3 ± 183.6 days, visual recovery was statistically significant in persistent eyes (BCVA 0.07 ± 0.07 logMAR; P < 0.00001) but, not in recurrent eyes (BCVA 0.16 ± 0.08 logMAR; P = 0.07). Five of 21 eyes were left with residual significant scar., Conclusion: The sequelae of microsporidial keratoconjunctivitis are not uncommon. Topical 0.03% tacrolimus ointment appeared to be an effective corticosteroid-sparing agent for the treatment of SEIs and prevention of recurrence., Competing Interests: None

The authors describe the case of bilateral herpes simplex keratoconjunctivitis (HSK) following uncomplicated 7 mm bilateral lateral rectus recessions in a 3-year-old child. The recovery was initially unremarkable, and the standard postoperative drops of dexamethasone and chloramphenicol (non-preservative free) were prescribed. The child presented 8 days postoperatively with fever, right upper lid swelling and ptosis. She was admitted for intravenous antibiotics for suspected pre-septal cellulitis. Over the next 2 days, she deteriorated with bilateral lid involvement. An examination under anesthesia (EUA) revealed bilateral corneal epithelial (dendritic and geographical) ulcers with conjunctival erosions and pseudo membranes prompting a diagnosis of HSK. This was confirmed by polymerase chain reaction (PCR) testing. The child recovered within 2 weeks after starting oral and topical antiviral medication. This case highlights the importance of EUA in infections not responding to standard treatment. Although HSK is known to occur after topical steroid use and ocular surgery, we were not able to find any other cases in the literature and believe this is the first reported case of bilateral HSK in the immediate postoperative period after strabismus surgery.

Objectives: The aim of this retrospective case-control study was to report the efficacy of subcutaneous triamcinolone as part of a regimen for feline eosinophilic keratoconjunctivitis (FEK)., Methods: Records and clinical photographs were reviewed and lesions semiquantitatively graded for cats with cytologically confirmed FEK. Clinical data were compared between a study population of nine cats (11 eyes) treated with, and a reference population of seven cats (eight eyes) treated without, a median of 0.11 mg/kg (range 0.10-0.20 mg/kg) of triamcinolone acetonide subcutaneously., Results: Breed, sex, age and prevalence of corneal ulceration at presentation; corneal disease severity before and at the initiation of immunomodulation; and duration of antiviral treatment before immunomodulation did not differ significantly between populations ( P ⩾0.059). Corneal plaques resolved in five cats each from the study and reference populations ( P  = 0.366). Median (range) time from immunomodulation to corneal plaque resolution did not significantly differ ( P  = 0.246) between the study (median 14 days; range 8-38 days) and reference (median 28 days, range 14-46 days) populations. No adverse reactions were attributed to triamcinolone administration, and all corneal ulcers in the study population re-epithelialized within 14 days (range 8-38 days) following triamcinolone injection. Time to corneal ulcer re-epithelialization following triamcinolone injection varied minimally in those receiving antivirals prior to (8 or 30 days until re-epithelialization), simultaneously with (38 days) or after (14 or 24 days) triamcinolone., Conclusions and Relevance: In otherwise healthy cats with FEK, subcutaneous administration of triamcinolone appears to be well tolerated and as efficacious as conventional topical immunomodulatory therapies. It may be especially useful in ulcerated eyes where topical immunomodulation is contraindicated.

Purpose: Investigation of the efficacy and safety of 12 months of topical tacrolimus 0.03% ointment treatment against the subepithelial infiltrates (SEIs) due to adenoviral keratoconjunctivitis (AKC) resisting at least 2 years was aimed., Methods: This case series included consecutive patients with SEIs secondary to AKC who were resistant to topical steroid and ciclosporin-A (CSA) treatment and treated with topical 0.03% tacrolimus (Protopic; Fujisawa Healthcare, Teva, Deerfield, Illinois, USA) for 12 months, at least 2 years after AKC. For the evaluation of treatment efficacy, best-corrected visual acuity (BCVA), Fantes score, corneal subepithelial infiltrate score (CSIS), Oxford score, Schirmer and tear breakup time results were evaluated. Intraocular pressure and complaints of the patients were followed for evaluating the safety profile of the treatment. The patients were followed after the baseline visit at the 1st, 3rd, 6th and 12th month., Results: 15 eyes of 11 patients with SEIs and 16 eyes of 16 healthy controls were included in this study. 1 patient (9.1%) could not tolerate the treatment. Significant improvements in BCVA, CSIS, Fantes score and Schirmer results were observed in the study group starting from the 3rd-month visit, and the improvements persisted until the end of 12 months of treatment., Conclusion: Topical 0.03% tacrolimus might show efficacy against the SEIs persisting at least 2 years despite corticosteroid and/or CSA treatment without any prominent side effect. While at least a period of 3 months was necessary for a significant improvement in the BCVA, SEIs and Schirmer results, a period of 6 months was necessary for a decrease in Oxford score., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To report a case of microsporidia (Encephalitozoon hellem) keratoconjunctivitis acquired through avian transmission in an immunocompetent adult, diagnosed by metagenomic deep sequencing (MDS), and confirmed by polymerase chain reaction., Methods: A case report., Results: An 18-year-old woman was referred with unilateral keratoconjunctivitis unresponsive to topical and systemic therapy after exposure to birdcage debris. Slit-lamp examination of the left eye revealed a follicular papillary reaction of the palpebral conjunctiva and multiple corneal punctate epithelial opacities that stained minimally with fluorescein. In vivo confocal microscopy revealed bright double-walled structures and smaller bright round structures in the superficial epithelial debris and epithelium. Molecular diagnosis with MDS of E. hellem was confirmed by polymerase chain reaction. Clinical resolution and normalization of in vivo confocal microscopy was observed after a 6-week course of topical azithromycin. The patient elected a 3-week course of topical voriconazole 1% for definitive antimicrosporidial treatment, with no evidence of persistent infection 1 month later., Conclusions: Microsporidial (E. hellem) keratoconjunctivitis can occur through avian transmission in immunocompetent hosts. Topical azithromycin may be effective against this pathogen. MDS has utility in the diagnosis of atypical keratoconjunctivitis., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms., (Copyright © 2020. Published by Elsevier Masson SAS.)